Saturday, 25 November 2017

Austerity and mortality

In a footnote in a
recent post, I noted the recent controversy over a BMJ paper
relating changes in the English mortality trend to austerity, and in
particular cuts in NHS and social care spending. With the journal’s
blog
headlining the paper as saying “Health and social care spending
cuts linked to 120,000 excess deaths in England”, headlines in the
press were inevitable. The BBC decided, however, to ignore the study,
based (in part?) on advice
from the Science Media Centre (SMC). One look at who funds that
centre (and putting aside bodies like the Medical Research Council!),
and a conspiracy was born.

Was the SMC’s
advice correct? Here is a chart from the paper that allows me to
explain the basic idea behind it. (The latest ONS data on mortality for the UK is
here.)

The vertical axis is
the mortality rate (see the paper for the exact definition). Since
2001 it has been declining over time. The blue line is what
extrapolating that trend would imply. However, as the red line shows,
since 2012 the mortality rate has flattened off. We could call the
difference between the actual and the trend line excess deaths, which
are the grey bars. Further analysis by the authors showed that these
excess deaths occurred in the over 60 age group.

Reductions in
hospital and social care spending could explain these excess deaths,
with lower social care spending in particular leading to a higher
number of deaths in care homes. The figure of 120,000 is the total
number of excess deaths between 2010 and 2017 estimated to be due to cuts. As you might say,
austerity kills.

This description
should I hope immediately show the potential fragility of the
results. Calculating the number of excess deaths relies on assuming a
simple trend decline in mortality which may not be realistic. Even if
it is, there are many other possible causes for these excess deaths,
and the authors were only able to test for a small number. The number
of data points is not large.

One obvious way to
try and see how speculative this analysis is would be to look at
other countries over this period. Has there been a similar levelling
off in mortality rates? What follows comes with a huge health warning
(forgive the inevitable pun): I am a complete amateaur at handling
data of this kind. Because data for the UK is more immediately
available to compare to other countries, I will look at the UK rather
than England.

Using data
from the World Health Organisation, we can indeed observe mortality
(defined simply as deaths divided by population) in the 75+ group
actually increasing between 2009 and 2013 in France as well as the
UK, but decreasing in Germany and Norway. (The reason for the choice
of countries will become clear.) Among the 55-74 age group, there
were declines of a similar size in all four countries.

Unfortunately we
really want to focus on the 65+ group. Another way of looking at this
issue is to examine data for life expectancy. The OECD produce this
data
at age 65. Obviously if mortality rates level off, so does life
expectancy. If we look at the UK, we can do something similar
(although rather simpler) to the analysis from the BMJ study shown
above.

UK life expectancy for women at 65 over time (source OECD), and 2001-2010 trend

We can see that
actual life expectancy at 65 for women (the blue line) was
increasing from 2001 until 2011 (the red line is a trend over this
period), but has subsequently levelled off, much as the mortality
rate does in the BMJ study. A similar pattern occurs for men,
although the actual numbers are lower throughout (unfortunately).

Has the same
levelling off happened in other countries? Which other countries
should we compare the UK to? We have two problems. First, mortality
and therefore life expectancy is related to geographically specific
factors, like average winter temperatures or local flu epidemics. It
therefore makes more sense to compare the UK to France than
Australia, say. Second, many other countries embarked on austerity
besides the UK. In the chart below I plot actual life expectancy for
women at 65 in the UK (as above), France, Germany, Norway and
Denmark. (Again the analysis would be similar for men.)

Life expectancy for women at 65 over time, various countries (source OECD)

One thing I did not
know until I did this analysis was how much higher French life
expectancy is. Yet as you can see from the red line, it too has
levelled off since 2011. That could be because expectancy is so high, it could also be because French people also experienced
austerity, or because of some other unexplained factor. Austerity in Germany was more modest than in France, and
perhaps by coincidence the recent levelling off (the yellow line) is
more moderate compared to its previous trend. One country that had no
austerity was Norway. As the green line shows any levelling off in
the rise in life expectancy since 2011 has been small. The rise in
life expectancy in Denmark (where again there was no austerity until
2013) did not change after 2011, but maybe that involves some
catching up.I admit it is
difficult to visualise trends on a chart with so many lines, so I
have done one for another country that has data very similar to
Norway and experienced no austerity, which is Sweden.

Swedish life expectancy for women at 65 over time (source OECD), and 2001-2010 trend

The trend, as with
the UK above, is estimated from data beginning in 2001 and ending in
2010. As we can see, actual life expectancy does appear to deviate
from trend in a downward direction from 2012 onwards, just as it did
in the UK. The difference is that whereas life expectancy is still
rising after 2011 in Sweden, in the UK it is flat. The gap between
the trend line and actual in Sweden is just 0.3 years, but in the UK
it is almost one year.Thus the two of this group of countries that have experienced a complete levelling off in life expectancy are France and the UK. Is this because both have experienced significant austerity. As far as health expenditures are concerned, the answer is no, as the chart below shows. For comparability I've shown the data relative to a trend for the 2001-10 period.

French health expenditure from 2011 has increased at the same trend as 2001 to 2010, whereas UK health expenditure has fallen away substantially.All this suggests
that there has been in many neighbouring countries some decline in
the rate at which life expectancy has been rising since 2011, but
only France and the UK have seen no rise in life expectancy since
2011. French life expectancy was already very high, so perhaps some levelling off was inevitable. Or alternatively there is some missing factor that explains the levelling off in life expectancy in France and the UK. One final statistic, to show that my choice of countries has not been rigged. If we compare life expectancy for women at 65 in 2015 to 2011, among all the OECD countries only one has seen a (slightly) bigger fall than the UK, which is Austria. The only country with the same decline as the UK is France. The real message is that this is an ideal area
for some proper research using proper
econometrics on a wider sample of countries.

I want to end by
making a more general point. Linking austerity to health is nothing
new. In this post
from 2013 I talked about the work of David
Stuckler and others. He has a recent paper
with coauthors on the health impact of Brexit in the Lancet. As Danny
Dorling explains in this excellent verbal account
of the UK data in the LRB, there have been a number of studies
linking excess deaths to austerity before the one discussed above.
You would think that a combination of the data and these studies
would prompt the government to at least investigate what is
happening, but they have so far done nothing. Perhaps they know what
the result of any investigation would be.

To see why this is
such a sensitive topic for the government, you only need to look
at a recent Question Time (9 minutes in) where Aditya Chakrabortty
talked about government policy leading to deaths. It is one thing for
economists like me to say that austerity has cost each household at
least £4,000: this can be dismissed with ‘what do economists
know’? But when doctors say the policy has led to premature deaths,
that is something else. If I was being cynical, I would say it is no
surprise that the BBC did not want to have anything to do with this
study.

"Calculating the number of excess deaths relies on assuming a simple trend decline in mortality which may not be realistic."

Trivially true, an eternal linear decline in mortality would first make people immortal, and then cause the dead to start resurrecting.

However, any long-term downwards trend in mortality is likely unrealistic, and it might be expected that it should increase at some point even with increasing life expectancy. The clearest example of this scenario is Japan, where mortality has been rising since the 80s despite life expectancy gains. This is because a greater percentage of the Japanese population is now elderly. Should we not expect a similar mortality rate turnaround to occur in the UK?

On the Question Time episode SW-L cites, I thought Aditya Chakrabortty made some excellent points. His take on the Budget can be found at https://www.theguardian.com/commentisfree/2017/nov/22/philip-hammond-budget-economy-brexit

You have provided an immense public service by bringing to light this important research paper. One of your finest blogs to date and I'm shocked there's been no reaction to it. The sideways movement of the mortality curve speaks volumes about the real costs of austerity and is a repudiation of all the silly sober belt-tighteners who pepper the blogosphere. No longer can they hide behind their euphemisms.

Just submitted a paper showing that there is absolutely no link between reductions in spending for individual local authorities across England, Scotland and Wales and the increase in deaths in these areas. The austerity theory was an urban myth

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